These last two days have been a whirlwind for the family. Unfortunately, I predict the coming months to be almost as difficult, although in a different way. Punctuated by moments of helpless loss, grief and guilt, the family will certainly explore unknown parts of their souls as they struggle to heal the wound of this loss. These dedicated family members have come and gone at all hours to visit this shell that was once their son, their twin brother, and their first true love. From these fine people, I have learned much about my patient, David Michael, and the brief life he led on this earth. I had to learn about this boy since I have alternately served as confessor, primary care physician, and surgeon for this young man and his family.

The pictures I have seen show an energetic young man of nearly 15 with dark blue eyes and wavy brown hair. I can see a certain glint in his eye that suggests he may have been ‘independently minded’; but who can mind that? His Mother has told me many stories about David’s life. Each tale hints at the charm possessed by the very young and the gifted ones who are possessed with a certain charisma. David was obviously both.

In the past two days, I’ve heard one story about a very young David hiding a dozen eggs around the house because he was ashamed that he had broken one of them. It was during the Holidays and Mother was expecting a house full of visitors. Of course the eggs began to smell, and as the family frantically searched for the source of the odor, David just as frantically denied any knowledge of the crime. Other favorites include stories from David’s twin brother about the times they used to switch places in school and other moments of opportunity. The girlfriend has told me that David was an awesome friend to her. She hints at more, but stops short of details and would never confess that they were young lovers. I suppose that David’s twin, Spencer, can take over where David left off. It would probably help both of them heal, and the two children already seem to be very close.

I worry most for the Mother and Spencer. Theirs is the most difficult sentence. Spencer’s fate is to be reminded of his brother every time he looks in the mirror. Their mother’s fate is to be reminded of her loss every time she gazes on her remaining son’s face. She has already confessed to me, in a quiet moment, that she watches over her sleeping son every night since the tragedy. She doesn’t think he knows- but Spencer has told me that he senses his mother’s presence every night.

They have said their goodbyes now to this shell that was a member of their family. As a father and surgeon who has seen death many times, I know how difficult those first steps are. The boy is brain-dead, as vague a definition as that is, but he still breathes and his heart yet beats due to the machines to which he is connected. His injury, while invisible, is inconsistent with life. He has not responded to any of the tests administered in the past two days, and has been declared brain-dead as of this afternoon. The inevitable approaches, but the difficulty is in saying goodbye to an apparently sleeping boy that to the eye appears as if he might awake at any moment. Saying goodbye is never easy- especially when saying goodbye to a child. As a friend I understand the family’s reluctance to leave. As a surgeon burdened with the task of removing viable organs for transplant, I must harden my heart against the emotional onslaught so that I can best do my job. A life is ended, but many lives can yet be saved.

As the family disappears around the corner, and their footsteps fade, I wave to the orderlies waiting with a gurney to take Donor #534223 to the surgery for organ harvesting. They gingerly transfer the donor to the gurney and cover him with a sheet as they would for any surgery patient, respecting the donor’s dignity even through he nears death. The portable ventilator is hooked up, and the Donor begins his last journey. When we arrive in the surgery, I review the final blood-work results to determine which organs are best suited for harvesting as the Anesthesiologist begins a slow drip of a paralyzing agent and anesthesia through the saline line and the nursing staff arranges the donor on the surgical gurney.

Donor #534223 is, other than his fatal injury, generally very healthy. His kidney function seems to have declined since the last time the lab tested their function yesterday, but it is still within tolerances to expect a successful transplant. I check each of the people in the room a final time before we begin, searching for imminent negative emotion. Seeing none, I signal the start of the operation.

The harvesting surgery is relatively simple. It is, of course, a final surgery and must be carefully choreographed to ensure that each organ is harvested and is sent on it’s way to the recipient as quickly as possible. There is an order to the surgery so that organs are taken based on their fragility or if they are needed to delay negative effects on other organs during the harvesting. Intestinal organs are taken first, followed by kidneys and liver. The heart is stilled at the very end and is lifted from the donor to travel in an ice bath to the surgical suite where the recipient lies unconscious, opened up and waiting for the arrival of this pink gift of life.

I have spoken with the donor’s family regarding a special transplant of organs that are not generally harvested. They have given their consent, so three surgical teams are now at work on the donor. Donor #534223 is still now, no longer breathing or possessed of a heart to beat. All life critical organs are on their way to the recipients and we are left harvesting other, less important things. Though generally considered unimportant, these things can make a critical difference in the recipient’s quality of life.

For example, an Ophthalmologist has harvested one cornea to help a child in our community who would otherwise be blind. A dermatologist has harvested skin grafts that will be used to treat burn victims. The grafts are taken in unbroken sections from the buttocks and inner thighs to reduce the possibility of scars or hair interfering with the gridding process.

As the Ophthalmologist worked, I labored at my own special project. I made sure that the Donor’s family understood the full implications of this specific donation, but was pleased to receive their permission to proceed once they had time to carefully consider the request. I have explained to the donor’s family how two young patients of mine, coincidently another pair of twins, had suffered from leukemia during their early puberty. Both had suffered swelling as part of their disease when infected white cells accumulated in their testicles. The radiation treatment necessary to save their lives resulted in the certain destruction of their generative organs. The result was that one twin had already undergone a bilateral orchidectomy simultaneously with insertion of cosmetic implants. The other still had his testicles, but they had been rendered completely useless and had visibly atrophied. In short, neither boy produced any meaningful level of testosterone. Puberty had been interrupted so abruptly that at 16, both boys appeared to be 13 or younger.

I had long pondered the idea of a testicle transplant to correct such a condition. It didn’t make any sense to me as a surgeon why testicles would not qualify for transfer to those who otherwise lacked them. Such a transplant would certainly require the same anti-rejection medicine as a heart or other thoracic organ. The recipient would be subjected to the same rigid selection standards, and would run the risk of rejection every day after the transplant. In short- I could not see any reason to block such a transplant from proceeding.

On a whim, I compared the genetic and blood characteristics of my prospective donor to my twin patients on the evening after young David had been brought to my hospital. I was pleased to find that the three boys were well enough matched to permit a transplant. I knew that the cultural and ethical implications are broad and that the surgery may not succeed, but I felt compelled to try the impossible, and hope for a miracle. So I sought the permission of the donor’s family, and received their permission through David’s twin brother this afternoon.

So now, as I look down at Donor #534223 and see that private place there between his legs, I do not think of his current circumstance. I wonder, during that brief moment of introspection, how many times he had stroked his erect penis to bring himself to orgasm. I wonder if he and his brother ever shared that joy together. I wonder if this boy ever penetrated his young girlfriend with his penis, pushing balls deep into her yielding flesh before emptying the contents of his testicles into her willing vagina. I can see the penis there, taped to the Donor’s right hip, lying flaccid with a catheter plunged between the lobes of the glans. Below it, relaxed in their thin sack lie the organs themselves. Average sized, but surely the most important things in the world to this boy before his accident, and soon to be of huge importance to two other needy boys.

I reach out, and grasping the Donor’s mostly hairless scrotum between my fingers, begin the cut that will harvest the testicles to live a little longer between the legs of another boy.

I remember, as the still blood begins to seep from the wound, how uncomfortable Spencer looked as he listened to his mother and I discuss the harvesting of his brother’s organs. His mother insisted on his being present and part of the conversation, but I still remember his shock on his face and how his hand cupped his crotch when the subject turned to the harvesting of his brother’s sexual organs. I’m sure, since his organs were presumably identical to his brother’s, that the conversation was a tad uncomfortable for him.

The first testicle is gone now, tied off and on it’s way to the young recipient in suite 3B. One more cut and I will carry this last remaining testicle to suite 3A where Zach, the twin leukemia patient waits unconscious for his new manhood.

With my final cut it is finished. Four hours of surgery led by my team to carry out the final wishes of the family. The family’s sacrifice will provide a miraculous gift to many deserving people who would otherwise face a lifetime of dialysis, liver failure, chronic asthma, or ongoing heart troubles that would doom each of them to a short life of pain, mediocrity and inactivity.

Another team will reassemble the Donor’s remains and see that they are passed to the appropriate mortuary. I pause a moment at the head of the gurney, and stepping away from my unemotional Surgeon role, breathe a soft “Thank You” into David’s unhearing ear.

Turning away from Death, I pick up the container holding the testicle in a static condition and carry it down the sterile hallway toward a future of Life.

Implant

Young Zach is heavily sedated on the surgery table. His head is turned to the side and he is naked and exposed on the gurney awaiting his surgery. With the help of my excellent nurses, I am only a few moments in my pre-op preparations. The testicle is taken into the surgery suite and is prepared for transplant just as any other organ would be. As I prepare for the coming procedure, I admire the boy laying on the gurney. The lights are focused on the boy’s crotch as the nurse shaves a last bit of pubic hair away from the surgery site. I remember how the winsome hair of a barely pubescent boy was evident above Zach’s otherwise immature uncircumcised penis. The whole miniscule package looks almost obscene on the crotch of boys as tall as the twins. Zach and Tyler are very handsome boys, and I wonder what effect testosterone will have on their bodies so late in adolescence. I hope, as I glove up, that they can handle the onset of a second puberty.

As I began the incision to access Zach’s young scrotum, a nurse whispered in my ear that Ty’s operation was so-far successful. I had some concerns for the success of the procedure on Zach’s brother since Ty was the one who had suffered the bilateral orchidectomy. The concern was that the blood vessels might have atrophied to the point that they could not be connected to the testicle. No connection equals no transplant. The nurse’s whisper put me at ease on that account and I faced the coming surgery with growing hope.

I opened the abdominal wall through the natural crease between Zach’s well defined abdominal muscles and his left thigh. I cleanly excised his damaged testicles from their connections and discarded them into a medical waste container. I finished with a small incision in the center of the scrotum to allow access for surgical reconnection of the new testicle. Having begun, I stepped aside to assist the newly arrived Urological surgeon as he connected the donor testicle to Zach’s body. Connections like the blood vessels were relatively simple. That connection was most important and was therefore the first to be undertaken in order to provide the testicle with life sustaining oxygen as soon as possible. Watching it, the moment of truth was like flipping a switch. The Urologist removed the clamp on the gonadal artery and the testicle instantly flooded with pink, life giving blood. Where before a lump of meat was obscenely connected to this fine boy, there was now an organ warming in it’s new life. Hopefully it would soon begin to respond to the signals coming from it’s new master’s brain and flood his barely pubescent body with hormones and their attendant desires.

The remaining connections were not so simple. Reconnecting the Vas Deferens is always a delicate procedure. It requires delicate, careful near-microscopic surgical skills. It is never easy, and I am glad that the Urologist had the experience to accomplish the impossible. After completing that connection, essentially a reverse vasectomy, the surgeon reconnected the nerves and fixed the testicle in it’s place within the scrotum. Stepping back, his gloved hands raised in supplication, the Urologist pronounced the surgery successful.

I closed by adding an artificial implant on Zach’s right side to visually balance the scrotum. A few stitches later, and Zach was off to the recovery room to wake next to his brother.

Recovery

As a new friend of the family, I was invited to the funeral service at the First Baptist Church one week later. It was a grand affair, attended by all the local politicians, David’s family and many elderly grandmother types from the local nursing home where David had sometimes volunteered. Zach and Ty, newly back on their feet and surely very sore, had ventured out of their home to mourn the passing of their friend. Due to patient confidentiality, neither Zach and Ty’s family, nor David and Spencer’s family knew anything about their new relationship. Even though they were ignorant of their new brotherhood, the three friends briefly embraced as Zach and Ty gingerly walked past the bereaved family and excited into the light.

Reunion

Those days are nearly fifteen years behind us now. I have retired from my surgical practice to a life practicing hook insertion on willing fish.

As has recently become the fashion, Donor families occasionally arrange a ‘reunion’ of sorts. These affairs are advertised over an Organ Donor network of donors, their families, surgeons and recipients. No one is ever forced to attend, but most do. Many times, once a reunion is announced, they become grand swinging parties. The families no longer mourn the loss- those feelings of grief are generally far in the past. They attend to celebrate an ongoing life: a life within and through strangers that would have otherwise been completely obliterated.

Tonight I have returned from my vacation home to attend the David Michael Life Party. Everyone is fifteen years older, but I can easily recognize many of the people attending. Scattered among many strangers, the recipients and their families, I recognize my old charge nurse and David’s mother. I recognize Spencer, and judging by the way they hold hands, he did marry his brother’s former girlfriend.

Just arrived just inside the door, I see Zach and Ty with their families. I see the proof of the successful testicle transplants running around the twins’ feet. A few moments later the three boys, old friends from school, migrate naturally toward one another. You can see the recognition in Spencer’s eyes. A moment more, and you recognize his realization of the meaning of Zach and Ty’s young children. The truth is a visible jolt to David’s grown twin brother, but he recovers quickly. A smiling Spencer kneels to meet his friend’s children, his nephews and niece, a spitting image of their father, David.